04584 (ELEC)T4ht 4 aCP Qum&
Building
Address 0" 4 91, 5,E113 ow,.
Owner
Mailing
Address ry 1- 2Qf3 Pike
City Zip Tel.
Contractor
I,..;11dTfUlek, :Garin
City (Zip
State Lic. City
& Classif. I Lic. #
Arch., Engr.,
Designer
Address Tel.
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
City I I
Zip State
i I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I herehy affirm that I am licensed under provisions of Chapter 9 (commencing with Section
700D) al ❑IVlslon 3 of the Business and Professions Code, and my license is in full force and
effect. '\ L .: Z. ".., r , .
SMNAT1nE _ _ DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Buslness and Professions Code: Any city or county which reQukes a
permit to construct, altar, improve, demolish, or ropair any structure, prior to its issuance also
reVires rho apokenl for such permit to W a signed siatemant that he is licensed pursuant to
the provisions of the Conlracler's license Law, Chapter 9 (commencing with Section 7000) of
DYvision 3 of the Business and Professions Code. of that he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (S500).
0 1, as owner of the properly, or my employees with wages as their sole compensation, will
do the work, and the structure is not Intended or offered for sale. {Sec. 7044, Bulsness and
Professions Code: The Cantractws License Law does not apply 10 an owner of Property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such knprovaments are not intandad or offered for sale. 11, however, the bulldfng
or improvement is .sold wlthln one year of compWion, the owner•buMer will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed ronlrartors to con-
elruct the project. (Sec. 7044. 9usinass and Profasslons Code: The Contractor's License Law
does not apply to on owner of property who bullds or fmproves thereon, and who contracts for
such projects with a conlraclaf(s) Ifcensed pursuant to the Contractor's L.kense Law.)
❑ I am exempt under Sec-B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (t 100) valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any pperson in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: ft, after making fhis CaditM a of Exempt 0ri you should become
subject to the Workers' Compensation pmvWms of the Labor Code, you must forthwith
comply with such provisions or fhis permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 160 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws rotating to building
construction, and hereby authorize representatives of this city to enter the above -
mentioned property for inspection purposes.
Signature of applicant _ Date
Mailing Address
City, State, ZIP
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number
Legal Description
Project Description
G31- 37r)'001
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation v
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE